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What Are Indications for Pelvic Examinations in Adolescents?

Patient Presentation A 16-year-old female came to clinic for her health maintenance examination. She had become sexually active in the past year with one partner. She did not anticipate being sexually active in the near future but she and her mother wanted to discuss options for possible birth control and sexually transmitted infection (STI) prophylaxis. She denied any gynecological problems. The resident did initial counseling with the adolescent but was unsure what, if any, testing needed to completed at this time.

The pertinent physical exam showed a healthy appearing adolescent female with growth parameters in the 10-50% and normal vital signs. Her general examination was normal including Tanner V staging and a normal external genital examination. The diagnosis of a healthy adolescent was made. During staffing, the attending physician also said that he was unclear if she needed a pelvic examination at this time because the guidelines had recently changed. Together they looked up the guidelines on the Internet and found that a pelvic examination was not indicated until she was 21 years of age. The adolescent and her mother were counseled that STI testing should be considered but that a pelvic examination was not needed at this time. The adolescent stated that she had used condoms and spermicidal jelly but she agreed to urine STI testing that eventually was negative. The adolescent was still unsure about initiating birth control, so additional handouts and website references were given to her.

Discussion
In 2010, the American College of Obstetricians and Gynecologists changed the recommendations for Papanicolaou (Pap) testing. The first Pap test is at 21 years of age regardless of the onset of sexual activity unless the patient has HIV or is immune suppressed and patients are then followed yearly after initiation of sexual activity. The reasons for this change are that although about 50% of high school students are sexually active, and about 50% of young women will have a positive test for human papilloma virus (HPV) within 36 months of initiating sexual activity, over 90% of the HPV infections will resolve within 24 months in patients with intact immune systems. HPV is the most common STI worldwide.

Adolescent patients who have previously been screened and have cervical atypia or neoplasia have different recommendations for followup and can be reviewed in To Learn More below.

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